I’m frequently asked by colleagues back in the states about how one provides psychological services in a combat/operational environment. Although we aboard Camp Fallujah are within the confines of a relatively large, well protected forward operating base, the front lines, such as they are in this conflict of insurgency and urban warfare, are never far away. Psychotherapy is conducted to the frequent accompaniment of outgoing artillery fire (incoming artillery fire is fortunately far rarer). In vivo exposure to potentially traumatizing events is a reality in this situation, where combat stress services are provided a few steps away from our surgical trauma bays in a ramshackle building requisitioned from Saddam’s army in 2003. Psychological services, like all medical services here, are provided by US Navy personnel, who as a part of the Navy-Marine Corps team provide all medical support to Marine Corps Warfighters. At any one time, approximately five Navy psychologists and five Navy psychiatrists are deployed in support of Marine and Navy personnel in Iraq and Kuwait, in addition to a number of psychiatric technicians. Our sister services also deploy significant numbers of mental health professionals in support of Army and Air Force troops.
I hope in this short letter to provide a brief description of how a psychologist- and his patients- fare in this environment. First, it’s important to note that the vast majority of the individuals stationed here will never seek out services for combat stress. All warfighters are changed by the experience of combat. Few are truly psychologically wounded by it, and fewer still to the point that they seek or require professional services. Most of the patients I see do not have diagnoses of Post-Traumatic Stress Disorder (PTSD) or related conditions; the modal diagnosis I encounter is likely to be an adjustment disorder or partner relational problem. Acute stress disorder is also not uncommon, as are insomnia and mild depression. However, a small but significant portion of my caseload is made up of Marines, Sailors, and soldiers who experience diagnosable symptoms of PTSD. I’ll share my thoughts about these patients in particular.
One thing I have realized in treating acute and post-traumatic stress disorder in combatants here in Fallujah is how much mythology has sprung up around PTSD. PTSD has developed a reputation like AIDS - dreaded, lifelong, with a universally poor outcome, and a disorder that only highly trained specialists can treat (often in some abstruse technique, like EMDR). This, however, is the point of view of the provider, not of the patient. I believe that we as professionals have gotten into this predicament because our conceptualizations of PTSD have led us down a path that results in over-pathologizing responses to traumatic stress and grief.
Sometimes our misunderstandings of PTSD reach the point of absurdity. Not too long ago, one recently-minted psychologist advised me that he had been taught that he couldn’t treat PTSD in theatre because his patients “were at risk of being re-traumatized.” This was a well-meaning and intelligent psychologist, but one who had been fundamentally miseducated about how to approach and manage PTSD. These misconceptions, I believe, are far more likely to result in permanent disability than early and direct interventions. Treated early and well, PTSD and related disorders are completely recoverable problems. But in order to treat PTSD in combatants, it is vital to understand not only the context in which the trauma occurs, but the culture and training of warfighters.
I treat a great deal of acute and chronic stress in theatre, using a basic cognitive framework that relies heavily on reducing affective response to distressing recollections and re-interpreting emotional and physical reactions to traumatic recollections. I combine this with a phenomenological/existential approach. I find that this approach is easily accepted by patients and assists them in integrating traumatic experiences into their lives. continued
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